Absence of association between hypertension and epistaxis: a population-based study

Endoscopic sphenopalatine artery electrocoagulation for refractory epistaxis: a clinical study

BACKGROUND

The electrical coagulation of sphenopalatine artery(SPA) under nasal endoscopy has gradually become an important surgical intervention for epistaxis.

AIM

To investigate the effectiveness and complications of SPA electrocoagulation for epistaxis.

MATERIAL AND METHODS

The clinical data of 47 patients undergoing SPA electrocoagulation were analyzed, retrospectively.

RESULTS

Forty-seven patients were enrolled, with a male to female ratio of approximately 3:1. 11of 36 were under 45 years old, 25 of 36were 45 years old and above. Among female patients, one was under 45 years old, and the others were 45 years old and above, but there was no significant difference in gender composition between different age groups (χ ² = 1.069, p = .301). All patients were unilateral epistaxis. The effective control rates of epistaxis within 24 h after surgery, early postoperative, and late postoperative were 100%, 100%, and 97.9%, respectively. There were 6 patients with complications, including 3 patients with nasal dryness and ecdysis on the affected side, 2 patients with numbness on upper lip, 1 patient with nasal adhesion and pus on affected side.

CONCLUSION AND SIGNIFICANCE

Refractory epistaxis has no relationship with age and sex, SPA electrcoagulation can effectively control refractory epistaxis and is an effective surgical method.

Association of Hypertension With the Risk and Severity of Epistaxis

IMPORTANCE

The association between hypertension and epistaxis has long been a subject of debate.

OBJECTIVES

To evaluate the risk of epistaxis in patients with hypertension using a nationwide population cohort and to assess the association of hypertension with the methods of managing cases of epistaxis.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, a hypertension cohort and comparison cohort were built using the Korean National Health Insurance Service-National Sample Cohort that represents the entire population of the Republic of Korea from January 1, 2002, to December 31, 2015. The hypertension cohort comprised 35 749 patients with a record of 3 or more prescriptions of antihypertensive medication and a diagnosis of hypertension (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code I10). Patients with other diseases associated with epistaxis, such as sinonasal tumors, facial trauma, bleeding tendency, and coagulation disorder, as well as those taking anticoagulant medications, were excluded. A comparison cohort comprised 35 749 individuals without hypertension matched sociodemographically in a 1:1 ratio. Statistical analysis was performed from January 1, 2019, to March 31, 2020.

MAIN OUTCOMES AND MEASURES

The incidence and recurrence of epistaxis were evaluated in both cohorts. The risk factors for epistaxis and management strategies were also assessed.

RESULTS

Among the 35 749 patients in the hypertension cohort (20 579 men [57.6%]; median age, 52 years [interquartile range, 45-62 years]) the incidence rate (IR) of epistaxis was 32.97 per 10 000 persons (95% CI, 30.57-35.51 per 10 000 persons); among the 35 749 individuals in the comparison cohort (20 910 men [58.5%]; median age, 52 years [interquartile range, 45-62 years]), the IR of epistaxis was 22.76 per 10 000 persons (95% CI, 20.78-24.89 per 10 000 persons) (IR ratio, 1.45; 95% CI, 1.29-1.63; adjusted hazard ratio, 1.47; 95% CI, 1.30-1.66). The IR of recurrent epistaxis was 1.96 per 10 000 persons in the hypertension cohort and 1.59 per 10 000 persons in the nonhypertension cohort (IR ratio, 1.23; 95% CI, 0.77-2.00). Patients with hypertension who experienced epistaxis were more likely to use the emergency department (odds ratio, 2.69; 95% CI, 1.70-4.25; Cohen h effect size, 0.27; 95% CI, 0.16-0.39) and receive posterior nasal packing (odds ratio, 4.58; 95% CI, 1.03-20.38; Cohen h effect size, 0.15; 95% CI, 0.03-0.26) compared with the comparison cohort.

CONCLUSIONS AND RELEVANCE

This study suggests that patients with hypertension had an increased risk of epistaxis requiring hospital visits. In addition, epistaxis in patients with hypertension appeared to need more emergency department visits and require more posterior nasal packing procedures compared with patients without hypertension. Medical counseling about epistaxis is advisable for individuals with hypertension, and the presence of hypertension should be considered in managing nasal bleedings.

Computed tomography findings in patients with primarily unknown causes of severe or recurrent epistaxis

Objective

In addition to rhinoscopy, computed tomography of paranasal sinuses (CT) may be performed on patients with primary unknown cause of severe epistaxis (SE) or recurrent epistaxis (RE) to further assess the potential cause of bleeding. The aim of this study was to evaluate CT findings during the work-up of intractable epistaxis patients.

Methods

6937 patients were treated in our emergency department with acute epistaxis between 2009–2018. 304/6937 patients underwent CT and rhinoscopy due to intractable SE or RE. 33 patients presented with head trauma prior to epistaxis and were excluded from the final analysis. In 271 cases the primary causes of SE (n = 252) or RE (n = 19) remained unknown. Two observers retrospectively evaluated CT scans for potential sources of epistaxis. Disagreement was settled by consensus. CT and rhinoscopy findings were compared.

Results

In 247/271 (91.1%) SE patients no related pathology was found on CT. A possible cause for epistaxis was found in all RE patients, but only in 5/252 (1.9%) patients with SE.

Most tumours (10/11) and inflammatory conditions (9/10) were found in patients with RE.

In three SE cases, a tumour was suspected on CT, from which two suspicions were refuted during rhinoscopy. CT revealed 10 cases of inflammatory conditions of the sinus and anatomical variant as potential cause of bleeding.

Conclusion

For patients with unknown causes of epistaxis, supplementary CT imaging may be a useful diagnostic add-on to rhinoscopy in the event of RE, tumour suspicion or inflammation of the paranasal sinuses. However, in most cases of first-time SE, CT does not necessarily add to the diagnosis. In these cases, the marginal benefit of CT needs to be weighed carefully against its risks.

The significance of atherosclerosis in hypertensive patients with epistaxis

BACKGROUND

The relationship between hypertension and epistaxis is controversial and poorly understood. The present research investigated atherosclerosis as a potential risk factor in hypertensive patients with epistaxis.

METHODS

A prospective study of 141 hypertensive patients with epistaxis was conducted. The laboratory tests included full blood count, lipid profile and coagulation profile. All patients underwent funduscopic examination of the eye and were classified in terms of four retinopathy grades.

RESULTS

There were strong positive correlations between the number of nosebleeds and retinopathy grade and low-density lipoprotein cholesterol level. There were weak correlations between the number of nosebleeds and blood pressure readings and triglycerides levels. Patients with grade III retinopathy, suggesting atherosclerosis, suffered from more frequent nosebleeds than other patients.

CONCLUSION

Atherosclerosis is one of the potential risk factors in hypertensive patients with epistaxis. This may have an impact on treatment choices.

Association between Hypertension and Epistaxis: Systematic Review and Meta-analysis

Objective Whether there is an association or a cause-and-effect relationship between epistaxis and hypertension is a subject of longstanding controversy. The objective of this systematic review and meta-analysis was to determine the association between epistaxis and hypertension and to verify whether hypertension is an independent risk factor of epistaxis. Data Sources A comprehensive search was performed using the MEDLINE, EMBASE, and Cochrane Library databases. Review Methods The review was performed according to the Meta-analysis of Observational Studies in Epidemiology guidelines and reported using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Results We screened 2768 unique studies and selected 10 for this meta-analysis. Overall, the risk of epistaxis was significantly increased for patients with hypertension (odds ratio, 1.532 [95% confidence interval (CI), 1.181-1.986]; number needed to treat, 14.9 [95% CI, 12.3-19.0]). Results of the Q test and I² statistics suggested considerable heterogeneity ([Formula: see text] = 0.038, I² = 49.3%). The sensitivity analysis was performed by excluding 1 study at a time, and it revealed no change in statistical significance. Conclusion Although this meta-analysis had some limitations, our study demonstrated that hypertension was significantly associated with the risk of epistaxis. However, since this association does not support a causal relationship between hypertension and epistaxis, further clinical trials with large patient populations will be required to determine the impact of hypertension on epistaxis.

Influence of air temperature variations on incidence of epistaxis

OBJECTIVE

Epistaxis is the most common ear, nose, and throat emergency observed in the emergency department (ED). An increased frequency of this condition has been observed during cooler months, but the results of available studies are controversial. The aim of this study was to investigate the seasonality and association of epistaxis presentations to a large urban ED with variations of air temperature and humidity.

METHODS

This study was a retrospective case series. Information on all the patients who presented for epistaxis in the ED of the Academic Hospital of Parma during the years 2003-2012 and ages ≥ 14 years were retrieved from the hospital data base, excluding those attributable to trauma. The chronologic data of all visits were associated with climate data (air temperature and humidity) by univariate linear regression analysis.

RESULTS

Among the 819,596 ED patients seen throughout the observational period, 5404 were admitted for epistaxis. Of these, 5220 were discharged from the ED, whereas 184 (3.4%) needed hospital admission. A strong seasonality of epistaxis was observed, with a peak during winter. A strong negative correlation was also found between the daily number of epistaxes and the mean daily temperature in the whole population as well as in patient subgroups (those undergoing anticoagulant or antiplatelet therapy, or those with hypertension, inherited bleeding disorders, liver cirrhosis, or advanced malignancy). A weaker correlation was also found between air humidity and epistaxis but only in certain subgroups.

CONCLUSIONS

The results of this study provided a contribution to improve our understanding of the epidemiology of epistaxis and for specific health policies that should also be planned by considering the seasonality of nosebleed.

Relationship between epistaxis and hypertension: A cause and effect or coincidence?

Introduction

Epistaxis is the most common otorhinolaryngological emergency. Whether there is an association or cause and effect relationship between epistaxis and hypertension is a subject of longstanding controversy.

Objective

The aim of our study is to evaluate the relationship between epistaxis and hypertension.

Materials and methods

This study was conducted at Olaya Medical Center (Riyadh) during the period between May 2013 and June 2014. A total of 80 patients were divided into two groups: Group A consisted of 40 patients who presented with epistaxis, and Group B consisted of 40 patients who served as a control group. Twenty-four-hour ambulatory blood pressure monitoring (ABPM) was performed for all patients. Patients were followed up for a period of three months.

Results

Readings of blood pressure (BP) were similar between the two groups regarding BP at presentation, ABPM, and BP at three months. There was a higher number of attacks in patients with history of hypertension. There was highly significant positive correlation between number of attacks of epistaxis and BP readings. Systolic BP at presentation was higher in patients who needed more complex interventions such as pack, balloon or cautery than those managed by first aid.

Conclusion

We found no definite association between epistaxis and hypertension. Epistaxis was not initiated by high BP but was more difficult to control in hypertensive patients.

Epistaxis: evaluation and treatment

Epistaxis, or nosebleed, is a common disorder that many patients will experience. Most patients go to the emergency room when they have an uncontrolled nosebleed, or they may present to an outpatient office. Most nosebleeds are not life-threatening and can be managed conservatively. Occasionally, hospital admission, referral to an otolaryngologist physician, and/or blood transfusion may be necessary. This article is an update on the latest information related to the prevention, causes, and treatment of epistaxis.

Is epistaxis associated with arterial hypertension? A systematic review of the literature

Both epistaxis and hypertension are frequent problems in the adult population. The relationship between the level of arterial pressure and incidence of epistaxis in a patient with hypertension is a question that appears frequently in the clinical practice. A systematic review of the literature regarding the relation of arterial hypertension with epistaxis was performed through MEDLINE and EMBASE. All studies, whether examining the correlation of arterial pressure at presentation of a patient with nasal bleeding or the repercussion of episodes of epistaxis in hypertensive patients, were included in this review. Studies were evaluated independently by two reviewers according to a standard evaluation form. Overall, nine studies fulfilled our inclusion criteria. Five of them were single-group (patient) studies, while the remaining four included a control group. In eight studies, the patient group included patients with epistaxis, while one focused on hypertensive patients. Six out of nine studies agree that arterial pressure is higher at the time of epistaxis, as compared to the control group or to the general population. Seven out of nine studies conclude that there is cross-correlation between arterial pressure and the actual incident of epistaxis. The presence of high arterial blood pressure during the actual episode of nasal bleeding cannot establish a causative relationship with epistaxis, because of confounding stress and possible white coat phenomenon, but may lead to initial diagnosis of an already installed arterial hypertension.

THREAT helps to identify epistaxis patients requiring blood transfusions

Objective

To analyze the characteristics of patients who needed a blood transfusion due to epistaxis-caused anemia and to define potential risk factors.

Design

Retrospective cohort study.

Setting

A total cohort of 591 epistaxis patients, prospectively included between March 2007 and April 2008 at the ENT department of the University Hospital of Zurich, was evaluated concerning the need for blood transfusions.

Methods

The clinical charts and medical histories of these patients were evaluated.

Main outcome measures

Common parameters that increase the risk for severe anemia due to epistaxis.

Results

Twenty-two patients required blood transfusions due to their medical condition. 22.7% suffered from traumatic nosebleeds. Another 27.3% had a known medical condition with an increased bleeding tendency. These proportions were significantly higher than in the group of patients without need of blood transfusion. The odds ratio for receiving a blood transfusion was 14.0 in patients with hematologic disorders, 4.3 in traumatic epistaxis and 7.7 in posterior bleeders. The transfusion-dependent epistaxis patients suffered significantly more often from severe posterior nosebleeds with the need for a surgical therapeutic approach.

Conclusions

Patients with severe nosebleeds either from the posterior part of the nose or with known hematologic disorders or traumatic epistaxis should be closely monitored by blood parameter analyses to evaluate the indication for hemotransfusion. The acronym THREAT (Trauma, Hematologic disorder, and REAr origin of bleeding → Transfusion) helps to remember and identify the factors associated with an increased risk of receiving blood transfusion.

Epistaxis and hemostatic devices

Epistaxis is a common medical problem that rarely requires surgical intervention. However, when medical or surgical intervention is required, epistaxis can sometimes be difficult to control. Knowledge of nasopharyngeal anatomy is absolutely essential to the proper management of epistaxis. This article begins with a discussion of the essential anatomy of the region and the basic epidemiology of epistaxis, followed by a review of initial treatment as well as devices and procedures specifically designed for the control of epistaxis. Advances and new devices for the control of epistaxis are described.

Epistaxis: some aspects of laterality in 326 patients

Lateralization of primary epistaxis was prospectively studied in 326 patients at Radebeul Elblandklinikum. The male-female-ratio was 1.3:1. A slight dominance of the right side (45% right vs. 39% left) was found in all patients. Further analyzed were the relationship to the localization of bleeding (anterior or posterior), the age and possible causes or risk factors. Nose bleeding from the posterior nasal portion appears to be statistically significantly higher than on both sides of anterior epistaxis. No statistically significant age dependence of laterality of epistaxis was observed in the age groups which we selected. However, nosebleed appears more frequently in women under the age of 50 years in both nostrils. With identified risk factors, idiopathic epistaxis occurs more frequently on the right side than does nosebleed. Mechanical trauma (intranasal sprays or nose picking) is a possible factor explaining the dominance of epistaxis on the right side, especially in idiopathic cases.

Serious spontaneous epistaxis and hypertension in hospitalized patients

The aim of the study was to evaluate the role of hypertension in patients hospitalized for serious spontaneous epistaxis. This 6-year retrospective study was based on 219 patients hospitalized in a University Hospital ENT and Head and Neck surgery department for serious spontaneous epistaxis. The following parameters were recorded: length of hospital stay, history of hypertension, blood pressure (BP) recordings (on admission, during hospitalization and on discharge), epistaxis severity criteria, including medical and/or surgical management of epistaxis (blood transfusion depending on blood count, embolization, surgery), medications affecting clotting. Epistaxis was classified into two groups: serious and severe. No significant differences were observed between the two groups in terms of age, sex ratio, history of epistaxis and BP characteristics including history of hypertension, mean BP on admission, mean arterial pressure on discharge and number of patients in whom BP was difficult to control. Patients with more severe epistaxis had a similar exposure to anticoagulant and platelet antiaggregant medications as patients with less severe epistaxis. Overall, on univariate logistic regression analysis, no factors were independently associated with severity of epistaxis. The pathophysiology of serious spontaneous epistaxis remains to be unclear. It concerns elderly patients (>60-70 years old) with a history of hypertension in about 50% of cases. Serious spontaneous epistaxis may also be the presenting sign of underlying true hypertension in about 43% of patients with no history of hypertension. However, hypertension per se does not appear to be a statistically significant causal factor and/or a factor of severity of serious spontaneous epistaxis.

[Current aspects in epistaxis]

A survey of current literature on the topic of epistaxis revealed only a circumscript number of publications with a high methodologic value. The analysis of these publications showed that there is a controversy on the necessity of routine coagulation tests in epistaxis patients. These tests should only be performed in cases with clinical evidence of a coagulation disorder. Also, there is an ongoing controversy on the value of local cooling with ice or cold packs. Nasal creams and decongestive nose drops have been found to be effective in uncomplicated epistaxis. Rhinoscopically and endoscopically targeted coagulation of bleeding vessels and nasal packing are recommended treatment options. There is a debate on discontinuation of anticoagulant therapy, if INR is within normal limits in Cumadin patients. Intractable epistaxis requires a broad armamentarium of different diagnostic and therapeutic options. Recurrent epistaxis in hereditary syndromes remains to be a challenge, although some advances have been made in diagnosis and symptomatic treatment. Some new medical drugs, as Viagra or Cialis may have nosebleeds as side-effects.

A retrospective study of 61 cases of spontaneous canine epistaxis (1998 to 2001)

OBJECTIVES

To determine the prevalence and identify possible clinicopathologic indicators of the diseases associated with canine epistaxis.

METHODS

The medical records of 61 dogs with epistaxis were reviewed.

RESULTS

Systemic diseases, diagnosed in fifty-six dogs, included canine leishmaniasis in twenty-three dogs, canine monocytic ehrlichiosis in twenty-two, concurrent canine leishmaniasis and canine monocytic ehrlichiosis in six, rodenticide toxicity in two and primary immune-mediated thrombocytopenia, suspected oestrogen toxicity and systemic arterial hypertension in one dog each. Intranasal diseases were documented in the remaining five dogs, including transmissible venereal tumour in three dogs, and nasal adenocarcinoma and nasal aspergillosis in one dog each. Mucosal pallor and a generalised bleeding tendency were significantly more common among dogs with canine monocytic ehrlichiosis compared with those with canine leishmaniasis, whereas the opposite was true for peripheral lymphadenomegaly. Also, dogs with canine monocytic ehrlichiosis presented with pancytopenia more frequently compared with those with canine leishmaniasis; in the latter dogs, the median values of haematocrit, leucocyte and platelet counts and serum total protein concentrations were higher.

CLINICAL SIGNIFICANCE

Canine leishmaniasis and canine monocytic ehrlichiosis are the leading causes of canine epistaxis in Greece. Mucosal pallor, bleeding tendency and pancytopenia are more likely to be indicative of canine monocytic ehrlichiosis, as opposed to peripheral lymphadenomegaly and hyperproteinaemia in canine leishmaniasis.

Clinical features of epistaxis in dogs: a retrospective study of 35 cases (1999-2002)

Epistaxis was retrospectively evaluated in 35 dogs. Systemic disease was diagnosed in seven dogs and intranasal disease in 29. Nineteen dogs with intranasal disease had neoplasia. Dogs with neoplasia were older (mean 10.0 years) than dogs with nonneoplastic intranasal disease (mean 5.6 years). Signs persisting for >1 month occurred more often in dogs with intranasal than systemic disease. Unilateral epistaxis did not distinguish intranasal from systemic disease. Only dogs with intranasal disease had facial deformity, decreased airflow, or regional sub-mandibular lymphadenopathy. Dogs with systemic disease had a lower packed cell volume (mean 31.8%) than dogs with intranasal disease (mean 42.7%).

Is admission for epistaxis more common in Caucasian than in Asian people? A preliminary study

OBJECTIVES

Epistaxis is a common ENT complaint. Although casual observation suggested that it is more common in Caucasian, compared with Asian people, a literature search failed to find any studies investigating ethnicity and epistaxis. The aim of this study was to identify any differences in emergency admission rates for epistaxis between Asian and Caucasian people.

DESIGN

Retrospective observational study using hospital computerised data (HISS).

SETTING

Large University Hospital accepting ENT emergencies.

PARTICIPANTS

All Asian and Caucasian patients admitted under ENT care as an emergency (1 January 2000 to 30 November 2005), split into two groups: one composed of epistaxis patients, the other of all other ENT emergency admissions.

MAIN OUTCOMES MEASURES

The proportions of Asian and Caucasian patients among the two patient groups, either epistaxis admissions or other ENT emergency admissions.

RESULTS

The proportions of Asian and Caucasian patients in the group admitted with emergency epistaxis were 7.1% (100/1410) and 92.9% (1310/1410) respectively. However, the proportions of Asian and Caucasian patients in the group composed of any other ENT emergency were 13.2% (729/5515) and 86.8% (4786/5515), respectively (chi-squared P < 0.01).

CONCLUSIONS

Caucasian people form an unexpectedly large, and Asians a smaller proportion of emergency epistaxis admissions. The possibility of an ethnic risk factor for epistaxis warrants further investigation.

Absence of association between depression and hypertension: results of a prospectively designed population-based study

The objective of this study was to examine the relation between hypertension and depression. In a cross-sectional study of the urban region of a State capital with more than 1.5 million inhabitants, 1174 men and women aged 18-80 years, selected at random from the population, were studied. Blood pressure, hypertension (blood pressure readings >or=140/90 mm Hg or use of blood pressure-lowering agents), risk factors for hypertension and depression according to the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) were investigated in home interviews. The prevalence of major depression and hypertension were 12.4% (95% confidence interval (CI): 10.5-14.3) and 34.7% (95% CI: 32.2-37.4), respectively. Systolic and diastolic blood pressures of individuals with and without a lifetime episode of depression were not different after adjustment for age and gender. Lifetime episodic major depression was not associated with hypertension in bivariate analysis (risk ratios (RR): 0.96, 95% CI: 0.76-1.23) and after adjustment for confounding (RR: 1.15; 95% CI:0.75-1.76). Hypertension and depression were not associated in this free-living population of adults, suggesting that their concomitant occurrence in clinical practice may be ascribed to chance.